HIV Perspective in Asia Praphan Phanuphak, M.D., Ph.D. Professor of Medicine & Microbiology, Chula. Univ. Director, the Thai Red Cross AIDS Research Centre Co-Director, HIV-NAT 14th BKK Int Symp HIV Med: January 19, 2011
Outline of the presentation
HIV epidemic in Asia HIV prevention in Asia
Overview Experience (Examples) Challenges
HIV treatment and care in Asia HIV research in Asia Conclusion
Asia is large and diverse
A continent with largest population Diverse geography (South, South-East, East and Central Asia), culture, religion & believes (Buddhism, Hindu, Muslim, Christian, Zen, etc.) Extremely diverse with regard to wealth (low, lowmiddle, high-middle & high income), infrastructure, HIV prevalence & HIV risk groups, competing national priorities & political commitment Level of wealth does not always reflect a better political commitment or better access to care & treatment
Adults and children estimated to be living with HIV 2009
Eastern Europe Western & Central Europe & Central Asia
820 000
1.4 million
[720 000 – 910 000][1.3 million – 1.6 million]
North America
1.5 million
East Asia
[1.2 million – 2.0 million]
770 000
Middle East & North Africa Caribbean
240 000
460 000
[400 000 – 530 000]
[220 000 – 270 000] Central & South America
1.4 million
[1.2 million – 1.6 million]
[560 000 – 1.0 million] South & South-East Asia
4.1 million
Sub-Saharan Africa
[3.7 million – 4.6 million]
22.5 million
[20.9 million – 24.2 million]
Oceania
57 000
[50 000 – 64 000]
Total: 33.3 million [31.4 million – 35.3 million] WHO/UNAIDS: December 2009
Regional HIV and AIDS statistics and features 2009 Regions Sub-Saharan Africa
22.5 million
Adults and children newly infected with HIV 1.8 million
[20.9 million – 24.2 million]
[1.6 million – 2.0 million]
Adults and children living with HIV
Middle East and North Africa
South and South-East Asia East Asia Central and South America Caribbean Eastern Europe and Central Asia Western and Central Europe North America Oceania TOTAL
Adult prevalence Adult & child (15-49) [%] deaths due to AIDS 5.0%
1.3 million
[4.7% – 5.2%]
[1.1 million – 1.5 million]
460 000
75 000
0.2%
24 000
[400 000 – 530 000]
[61 000 – 92 000]
[0.2% – 0.3%]
[20 000 – 27 000]
4.1 million
270 000
0.3%
260 000
[3.7 million – 4.6 million]
[240 000 – 320 000]
[0.3% – 0.3%]
[230 000 – 300 000]
770 000
82 000
0.1%
36 000
[560 000 – 1.0 million]
[48 000 – 140 000]
[0.1% – 0.1%]
[25 000 – 50 000]
1.4 million
92 000
0.5%
58 000
[1.2 million – 1.6 million]
[70 000 – 120 000]
[0.4% – 0.6%]
[43 000 – 70 000]
240 000
17 000
1.0%
12 000
[220 000 – 270 000]
[13 000 – 21 000]
[0.9% – 1.1%]
[8500 – 15 000]
1.4 million
130 000
0.8%
76 000
[1.3 million – 1.6 million]
[110 000 – 160 000]
[0.7% – 0.9%]
[60 000 – 95 000]
820 000
31 000
0.2%
8500
[720 000 – 910 000]
[23 000 – 40 000]
[0.2% – 0.2%]
[6800 – 19 000]
1.5 million
70 000
0.5%
26 000
[1.2 million – 2.0 million]
[44 000 – 130 000]
[0.4% – 0.7%]
[22 000 – 44 000]
57 000
4500
0.3%
1400
[50 000 – 64 000]
[3400 – 6000]
[0.2% – 0.3%]
[<1000 – 2400]
33.3 million
2.6 million
0.8%
1.8 million
[31.4 million – 35.3 million]
[2.3 million – 2.8 million]
[0.7% - 0.8%]
[1.6 million – 2.1 million]
WHO/UNAIDS: December 2009
HIV prevalence in Asia Country Thailand
% adult prevalence 1.3%
Number of HIV-infected 530,000
Cambodia
0.70%
57,900
Myanmar
0.61%
238,000
Vietnam
0.44%
254,000
India
0.29%
2,270,000
China
0.06%
740,000
UNGASS 2008-2009 Report
The Asian HIV Epidemic
Started around 1984-1986, 3-5 years after the Western world Mostly brought in by foreigners or by returned citizens traveling or living abroad or by imported blood products Thus, it was easy in the early day to blame foreigners, forgetting that it could be a domestic problem, an unfortunate lag time for prevention has been wasted. Interestingly, after more than 2 decades of epidemic in Asia, the epidemic in most Asian countries still remains concentrated in â&#x20AC;&#x153;risk groupsâ&#x20AC;? (MSM, IDU, FSW).
HIV prevalence among Asian MSM Country (City)
HIV prevalence Year
Cambodia
0.7-8.7%
2005
China
2.1-9.1%
2006-7
Hong Kong
4.1%
2006-7
Indonesia (Jakarta)
8.1%
2008
Lao PDR
5.6%
2007
Myanmar
29.3%
2007
Philippines (Manila)
0% (N=500)
2006
Singapore
4.2%
2007
Taiwan (Taipei)
8.5%
2004
Thailand (Bangkok)
17.3-30.8%
2003-7
Vietnam
0-7.8%
2008
Source: van Griensven F et al, Curr Opinion HIV/AIDS 2009; 4: 300-307
Transition from risk groups to general population: A lesson from Thailand
First Thai patient with AIDS diagnosis returned home from USA in late 1984 and died the same year Thailand first 2 de novo cases of AIDS were diagnosed in February 1985 at Chulalongkorn Hospital using clinical, OKT4, OKT4/OKT8 ratio and T cell mitogen (PHA) stimulation. 1984-1987: homo/bisexual 1988: Intravenous drug users (IDU) 1989: Female sex workers (FSW) 1990: Clients of FSW (males with STD) 1991: Pregnant women and newborns, i.e., general population From concentrated epidemic to generalized epidemic once the epidemic reaches FSW.
Why HIV epidemic still remains concentrated in many Asian countries?
The answer still remains unknown. Low cross spreading between risk groups (e.g., MSM & FSW, IDU & FSW) or between risk groups (e.g., FSW) and general population Low number of sex workers or less clients per sex worker Low extramarital sex Higher level of knowledge and awareness High condom use especially in commercial sex High male circumcision coverage Simply just a matter of time
Low rate of consistent condom use among Thai youth: 2009 survey % History of consistently using condom when having sex during the past year
Percent condom use
G. 8
G. 11
Vocational students
Male military conscripts
100 80
69
65
60
57 49
48
52
55
45
40
42 27
23
20
26
20
16
0
Men: with FSW
Men: with other men
Men: with lover
Thailand MOPH-U.S. Source: Behavioral surveillanceCDC using Collaboration hand-held computer, Bureau of Epidemiology
Women: with lover
Warning signs of rising HIV epidemic in Thailand Unsafe sex behaviors among sentinel
population were observed Using illicit drugs among youth was observed High HIV prevalence among hard to reach population, including street FSW, MSM, IDU, migrant workers and fishermen Increasing trend of HIV incidence among pregnant women and not decreasing trend of HIV incidence among male military conscripts STD is increasing sharply A second wave of HIV epidemic in Thailand is anticipated: a useful lesson for other Asian countries
HIV Prevention in Asia: Overview
Mostly focused on â&#x20AC;&#x153;risk groupsâ&#x20AC;? whereas general population needs more attention in order to prevent transformation of concentrated epidemic into generalized epidemic. 100% condom use in commercial sex is being implemented in many countries but not sustainable. Harm reduction including needle exchange program is expanding into many countries including Thailand. All conventional prevention strategies turn out not to be very effective in preventing new HIV infection. New prevention strategies are urgently needed e.g., routine HIV testing, earlier ART, PrEP, microbicide, etc
HIV Prevention in Asia: Experience
100% condom use in Thailand in mid-1990s worked but did not sustain. ALVAC prime / AIDSVAX boost reduced HIV infection by 31.2% in Thais (2009). Results of oral TDF in preventing HIV among Thai IDU will be out soon. Provider-initiated counseling and testing (PICT) is being implemented at the Thai Red Cross Anonymous Clinic and all Bangkok Metropolitan Administration health clinics and Thailand is going to implement the Routine (annual) HIV testing strategy soon.
The PICT approach of the Thai Red Cross Anonymous Clinic Family planning services
Cervical & anal Pap smear
STD screening & treatment
HIV Counseling & Testing Nutrition services Health check up packages Special events campaign & outreach activities
PICT for MSM at the TRC-AC
Provider-initiated testing and counseling for HIV in the Thai Red Cross MSM Sexual Health Clinic
Among 1,429 MSM clients in 2009 52% known HIV+ve 35% known HIV-ve and 13% unknown HIV status
Previous HIV status
STI MSM clients
Anal Pap MSM clients
HIV-ve Unknown HIV-ve
Unknown
Acceptance of HIV testing 34%
98%
77%
85%
% tested +ve for HIV
13%
13%
33%
8%
HIV Prevention in Asia: Challenges
Complacency of political leaders Controversies need to be settled e.g., condom distribution in school, needle exchange, routine HIV testing, etc. More ART coverage: treatment as prevention Higher coverage of PMTCT especially HAART for all pregnant women and formula feeding Adequate resources for HIV prevention, not what remains after treatment & care Prevention for marginalized and illegal populations More prevention trials in Asia in populations with high enough HIV incidence HIV-associated stigma & discrimination to be removed
HIV treatment & care in Asia: Overview Asia as a whole has a better healthcare infrastructure than Africa. BUT Asia has the same level of ART coverage as Africa (31% vs. 37%) although most generic ARV and its raw material are produced in Asia and the total number of patients who need ART is several magnitudes lower in Asia. In addition, PMTCT coverage in Asia is much lower than Africa (32% vs. 54%) Most treatment programs in Asia depend on external funding except Thailand, China, India
Number of people (all age groups) receiving and needing antiretroviral therapy, and percentage coverage in lowand middle-income countries by region, 2008 to 2009
WHO/UNAIDS/UNICEF: Towards Universal Access, Progress Report, 2010
Percentage of pregnant women living with HIV receiving antiretrovirals for preventing mother-to-child transmission of HIV in low- and middleincome countries by region, 2005, 2008 and 2009
WHO/UNAIDS/UNICEF: Towards Universal Access, Progress Report, 2010
HIV treatment & care in Asia: Experience
Large ART program started in the early 2000: Thailand (2000), Cambodia (2001), China (2002), India (2004), Vietnam, Myanmar (2005). All programs expand rapidly. Increasing number of patients on ART (from 160,000 patients in 2005 to 720,000 patients in 2009) but this accounts for only 31% (range: 16-93%) of those who were in need in 2009. Only Cambodia, Thailand and PNG have achieved the universal access goal of 80% coverage. AZT(d4T)/3TC/NVP is the most frequently used 1st line Routine VL monitoring is scanty. 65-88% remain alive and on treatment at 1 year. Loss to follow-up at 2 years = 8-16% Srikantiah P et al, AIDS 2010: 24 (suppl 3): S62-S71.
Number of enrollment into ART program
Enrollment into ART program under the National Health Security Office (77.7%)
250,000
216,118
(67.1%) 200,000
185,086
(52.9%) 142,390
150,000 120,000
(41.0%) 88,261
100,000
58,133 50,000 0
0
2541
2542
19,551 1,710 3,640
0 2543
2545
2546
2547
2548
2549
2550
77.7% coverage of those who needed ART in 2009
2551
2552
HIV treatment & care in Asia: Challenges
Implementing the new WHO Treatment Guidelines
How to get patients diagnosed early such as PICT? Cost of earlier treatment & coverage
Treat more people with CD4 <200 or to cover people with CD4 <350?
Laboratory monitoring (VL, resistance) Coverage of 2nd and 3rd line ART Manpower shortage: Task shifting
Short-term care: STD, reproductive health needs Long-term care: HIV and age-related metabolic complications, chronic diseases & malignancies More dependent on national budget Adherence and lost to follow-up Test every one and treat every one (Test & Treat)
The Thai-Australian Collaboration in HIV Nutrition (TACHIN)
Funding from AusAID Extension into Lao PDR: L-TACHIN project
Asia-Pacific Collaborating Centre in HIV Nutrition: A partnership between TRC-ARC, ASC and WFP
Prevalence of anal dysplasia by anal Pap smear among Thai MSM clients of the TRC-AC
174 Thai MSM clients of the Thai Red Cross Anonymous Clinic, 68% HIV+ve, mean age 32.1 years
Sensitivity of anal cancer screening is being enhanced by high resolution anoscopy with biopsy, p16 & MCM protein intracellular immunocytochemistry , E6/E7 mRNA and HPV typing Li A, Phanuphak N, et al. STI 2009;85: 503-507.
Nittaya Phanuphak et al, 2011
HIV research in Asia: Overview
Many Asian countries have expertise and infrastructure to do HIV research: clinical > basic research but they lack financial resource. Initially, they collaborated with scientists from the West who had more expertise and more funding. Now more LMIC countries (China, Thailand) invest more in research but many high income Asian countries (Japan, Singapore, S. Korea, Taiwan) are not so committed for HIV research or joint research. Asia used to be a leader in HIV research among developing countries but is now behind Africa due to more global interest in Africa.
Why wealthy Asian countries are not so committed in HIV / AIDS ?
Low HIV prevalence in their own countries Afraid of non-popular acceptance by their voters if large amount of budget is spent on HIV prevention due to stigma related to sex, condom and drug abuse Non-profitable investment in R&D for HIV prevention (e.g., vaccine) & care (e.g., ARV) Do not believe that economic breakdown in other countries as a result of HIV/AIDS will affect their own economy Refer their responsibility to USA and other Western countries who are harder hit by the epidemic Lack of regional concerted effort and political push
HIV research in Asia: Examples First ARV trial in Asia at Chulalongkorn University Hospital & Siriraj Hospital in 19921994 comparing AZT 250 mg bid vs. 100 mg tid and 200 mg hs (with Prof. Scott Hammer) First HIV vaccine trial in Asia was done in Thailand (TRCS) and China in 1994 using octameric synthetic V3 peptide. HIV-NAT, Asiaâ&#x20AC;&#x2122;s first HIV clinical trials centre was established in 1996.
The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT) International AIDS Therapy Evaluation Centre (IATEC), Amsterdam. Prof Joep Lange Thai Red Cross AIDS Research Centre (TRC ARC) Bangkok. Prof Praphan Phanuphak
HIV-NAT
National Centre in HIV Epidemiology and Clinical Research (NCHECR), Sydney. Prof David Cooper
HIVNAT
HIV-NATâ&#x20AC;&#x2122;s Network Nakornping Hospital Sanpatong Hospital Perinatal HIV Prevention Trial Network (PHPT) Chulalongkorn Hospital HIVNAT
Chiang Rai Hospital Khon Kaen Hospital Srinagarind Hospital Khon Kaen University
National Pediatric Hospital Social Health Clinic Phnom Penh, Cambodia
Siriraj Hospital Bamrasnaradura Institute Ramathibodhi Hospital Vajira Hospital
Queen Sawangwattana Memorial Hospital
HIV research in Asia: Examples (2) Thailand was the first among developing countries in doing PMTCT and efficacy HIV vaccine trials. Many Asian countries are sites for many international research networks e.g., NIH (ACTG, PACTG, HPTN, INSIGHT), CDC, ANRS, AVAN, NCHECR/UNSW TREAT Asia
Therapeutics Research-EducationAIDS Training in Asia (TREAT Asia)
The largest and most active HIV research network in Asia, established in 2000
TAHOD: An HIV observational database from 18 clinical sites in 13 countries / territories in Asia with coordinating centre in Australia (NCHECR) TApHOD: A pediatric observational database TASER: TREAT Asia Studies to Evaluate Resistance & TASER-pediatric sites TAQAS (TA Quality Assurance Sites)
It also networks with other large cohorts in Australia, USA, Europe and Africa
HIV research in Asia: Challenges
More innovative young Asian researchers Research as a career apart from â&#x20AC;&#x153;Routine to Researchâ&#x20AC;? More research on basic, behavioral and operational sciences More funding both nationally, regionally and globally (How to compete with Africa?) Truly collaborative with capacity building and equal sharing including authorship
Conclusion Asia has the potential to have devastating generalized HIV epidemic like that in SubSaharan Africa due to its large population and the presence of all high risk behaviors. Political commitment is essential to reverse the epidemic or to prevent the transformation from concentrated to generalized epidemic. Commitment has to come with their own national resources of which can be enhanced by regional and international collaborations.
Asia as a platform for international collaborative research in HIV/AIDS
Much less interest as compared to Africa USA, France and Australia are main players in bilateral collaboration. Many of the earlier researches were not ethically perfect and less capacity building or equal sharing, i.e., parachute-type research. Now it is much improved but still some â&#x20AC;&#x153;authoritative territoryâ&#x20AC;? or monopoly if collaborate with the national authority. In a country where many international agencies are working in, it will be nice if these agencies can collaborate to come up with an integrated program across its own boundaries to avoid duplication and to maximize the benefit of the host country. Country needs to prioritize their needs in order to select a right international partner that can meet their needs.